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Principles of Local Flaps in Plastic Surgery: Presented By: Dr. Deepak Krishna Dr. Shamendra Anand Sahu
Principles of Local Flaps in Plastic Surgery: Presented By: Dr. Deepak Krishna Dr. Shamendra Anand Sahu
Term “Flap” :
Originated from the 16th century Dutch word
“FLAPPE” which means “anything that hung broad and
loose, fastened only by one side”.
Timeline of the development of flap surgery
600 BC Sushruta Samhita Pedicle flaps in the face and forehead for
nasal reconstruction
1597 Tagliacozzi Nasal reconstruction by tubed pedicle flap from arm; described
“delay” of pedicle flap
1896 Tansini Latissimus dorsi musculocutaneous flap for breast
reconstruction (post- mastectomy)
1920 Gillies Tubed pedicle flap
1946 Stark 1 Muscle flaps for osteomyelitis
1955 Owens Compound neck flap
1963 McGregor Temporalis flap
1965 Bakamjian Deltopectoral flap
1971 Ger 11 Lower extremity musculocutaneous flap
1972 McGregor and Jackson Groin flap
1972 Orticochea 1 Musculocutaneous flaps
1977 McCraw et al Musculocutaneous territories
1981 Mathes and Nahai Classification of muscle flaps based on vascular anatomy
1981Ponten described fasciocutaneous flap
BASED ON LOCATION OF DONOR SITE
LOCAL FLAP
They are most prevalent in the supply This arrangement is most common
of skin covering the broad, flat between the longer, thinner muscles of
muscles of the torso. the extremities.
Example : Example :
latissimus dorsi flap, rectus abdominis Radial forearm flap, Dorsalis pedis flap
flap
WHY ?
DEEP
FASCIA
TORSO LIMBS
WELL DEVELOPED DEEP FASCIA DEEP FASCIA IS MORE RIGID , NOT
COVERING THE BROAD ONLY COVERING THE MUSCLES
MUSCLES WHICH IS ELASTIC BUT ALSO FORMS
PERMITING EXPANSION OF INTERCOMPARTMENTAL FASCIAL
ABDOMINAL MUSCLES . SEPTA BETWEEN MUSCLES
PROVIDING ANCHORAGE TO THE
VESSELS.
MUSCULOCUTANEOUS
/SEPTOCUTANEOUS
ARTERIES
CUTANEOUS
CIRCULATION
DIVIDED
INTO 3
LEVELS
skin fascia
subcutaneous
fat
At the above said three anatomic levels 6
recognizable vascular plexus exists as shown in
figure :
Fascial plexus : divided into
1) Subfascial plexus :
plexus lying on the under surface of the fascia .
relatively minor plexus .
incapable of sustaining a fascial flap .
It was not until the early 1900s that the concept was recognized.
• Defect
size, placement
• Surrounding skin
lesions, laxity, color match, scars
• Facial structures
functional concerns, lip, lid
• Incision placement
Resting skin tension lines
Planning
• Template
• Draw options/Measure
• Planning in reverse
• Incise
• undermine
• Rotate vs. advance vs. transpose
• Key stitches
• Close
Advancement Flaps
• First employed by Celsus
in ancient
Rome, popularized by
French surgeons in the
first half of 19th century
• Was called as “sliding
flaps”
• Moves directly forwards
into the defect without
any lateral movement
Advancement Flaps
• Execution is facilitated by presence of excess
skin
• More feasible in elderly or when skin elasticity
is more like in very young
• Usually rectangular, perpendicular to the lines
of minimal tension
• Uses – forehead , brow
Procedures devised to
facilitate advancement
•Excision of Burrow’s
triangle
•Counterincision at the
flap base
•Triangular design of the
flap
•Curvilinear design of the
flap
•Z-plasty at the base
Advancement Flaps
Burrow’s
triangle
at the
base of
the flap
V-Y Advancement flap Bilateral advancement flaps
V-Y Advancement Flap
Design
•Advancement should be
directed over the shortest
diameter of the defect
•The size of the V base
should match the size of
the largest diameter of the
lesion
•The V must be long
enough to allow tension-
free suture of the Y
V-Y Advancement Flap
•Advancement flap involves movement in two planes-
vertical and horizontal
•Pivot point on vertical plane which actually acts as a
pivot plane
•Pivot plane is the base of the flap at which the flap is
attached to the body
V-Y Advancement Flap
• α angle is determined by
– Location of defect
– Elasticity of the surrounding tissues
– Recommended to range between 20°-40°
• For leg defects, small angle is recommended
as there is less elasticity
• Gluteal region- large angle is planned
Bipedicle Advancement Flap
Multiple Y-V advancement
W Plasty or Zigzag plasty
• Used to break
up a single
linear scar
• For scars that
do not require
lengthening
• It redistributes
tension along
the length of
the scar
M-Plasty
• A useful technique to preserve
healthy tissue in scar revision
• lessen the chance of standing
cone (ie, dog-ear) deformity
• The M-plasty, by creating 2
separate 30° angles instead of
one
Pivot Flaps
• Derives its name from the pivot point at the
base
• The arc of rotation is under maximum tension
• 2 types
– Transposition flaps
– Rotation flaps
Transposition Flap
• Usually rectangular or square flap
• Transferred in a direction at right angles to
that of the blood supply
• Additional length- Back Cut
• Donor site
– Skin graft
– Another flap
Transposition Flap- DESIGN
• Recipient defect is
triangulated
– Right angle triangle
– Hypotenuse- near
border of the flap
– The right angle
assumes a position
opposite the flap
– In scalp defects, apex
should direct towards
the periphery of the
scalp
• Pivot point D- across the base of the flap, parallel and equal to
AB
• From D, a line is drawn parallel to BC
• With point D as axis, an arc is drawn from A and it intersects the
line at E
• CB is extended to meet the arc at F
• CFED is the marked flap
• Flap transposed and donor area is grafted
• In lower extremity length : breadth should be 1:1
Rhomboid flap described by Limberg in
1963
Dufourmentel Flap
• Designed by a French
Surgeon, Claude
Dufourmental in 1962
• The defect is tailored in
the shape of a rhombus
(with all sides equal)
• The short diagonal (BD)
and one of the adjacent
side (CD) are extended
Dufourmentel Flap
•Angle HDP is
bisected
•Line DE equals the
side of the rhombus
•EF is drawn parallel
to AC and equal to
side of the rhombus
Dufourmentel Flap
For square
defect, both
diagonals are
equal, eight flaps
can be designed
Bilateral Rhombic flap
Triple Rhombic flap
• Circular cutaneous defect
conceptualized as hexagon.
• Sides of hexagon are equal
to radius (r) of circle.
• First side of flap created
by direct extension equal in
length to radius at alternative
corners to prevent sharing
• of common sides.
• Second side of flap designed
parallel to adjacent side of
hexagon.
Bilobed Flap
• Consists of two lobes of skin and subcutaneous
tissue based on a common pedicle
• Design
– Primary flap is smaller than the defect
– Secondary flap is more triangular in shape
• Optimal angle between the two flaps is 90°, can vary
between 45° and 180°; greater the angle, larger the
resultant dog-ear
• Zitelli's modification (1989), the primary flap is
oriented 45° from the axis of the defect, and the
secondary flap is oriented 90° from the axis of the
defect; eliminate dog ears
• Convert the defect to a "tear drop" shape by the
excision of a triangle on the side of pedicle base
• Use a caliper as a protractor, with one tip placed at
the apex of the wound, to mark out two semicircles
• Outer semicircle defines the necessary length
of the two lobes
• Inner semicircle bisects the center of the
original wound and continues across the
donor skin, defines the limit of the common
pedicle of the two lobes
• Two lines are drawn from the apex of the wound
– First line is placed 45° from the axis of the wound
– Second line is placed 90° from the axis of the wound
– These two lines mark the central axes of the two lobes
of the flap
• Draw the flap with each lobe beginning and ending at
the inner semicircle and extending to the outer
semicircle at the point where it crosses its central axis
Z Plasty
• Involves transposition of two interdigitating
triangular flaps
• Effects
– Gain in length along the direction of the common
limb of the Z
– Direction of the common limb is changed
• Uses
– Prevention and treatment of contracted scars
– Scar revision
• In 1856, Denonvilliers first described the Z-plasty
technique as a surgical treatment for lower lid
ectropion.
• The first reference to this technique in American
literature was in 1913, by McCurdy, as treatment for
contracture at the oral commissure.
• Limberg, in 1929, provided a more detailed
geometric description.
• Numerical data showing optimal angles and length
relationships of Z-plasty limbs are credited to Davis
(1946).
• Release of contracture
– The central limb is placed along the line of
contracture- contractural diagonal
– 60° angle taken on each side and limbs of Z drawn, all
equal in size
– Longer diagonal is the transverse diagonal
•The contractural diagonal is under tension and
springs up when flaps are raised
•Causes change in shape of the parallelogram
•Contractural diagonal lengthens
• Mechanism of lengthening by Z plasty
– Length of contractural diagonal less than transverse
diagonal before release
– Contractural diagonal lengthens at the expense of
transverse diagonal
– Thus need for transverse skin laxity for contracture
lengthening
– Variables in construction of Z Plasty
• Angle size
• Limb length
• Angle size
– Length increases with in angle
30 25
45 50
60 75
• Angle size
• Trapdoor scars
• Significant subcutaneous scarring producing
contracture beneath the entire area of
trapdoor
• Z-plasty lengthens the marginal scar and
breaks up the subcutaneous scarring
Four-Flap Z-plasty
The 5 – Flap plasty
or “Jumping Man” flap.
Rotation –advancement Flap
• Semicircular flap which rotates around a pivot
point
• Located along tension lines
• Flap designed quite large than the defect to
ensure primary closure of the donor site
• skin graft or another flap are alternatives for
the donor site
• Tissue can move into an
adjacent defect in 2 directions.
• It can advance in a straight line
(ie, advancement flap), or the
tissue can rotate into the defect
(ie, rotation flap).
• The distinction between the two
is not always clear, and one type
of motion blends into the other .
• Furthermore, a single flap can
have both straight
(advancement) movement and
rotational (rotation) movement.
•Triangulation of the
defect
•Isoceles triangle
•Apex towards flap
pedicle
•Apex angle <30° to
avoid buckling of the
skin
•PIVOT POINT D- on a
projection of line AC, atleast
CD>2AC
•E is located midway between
AD
•An arc is drawn from B to D
• Pain reliever
• Wound care
• antibiotic ointment
• Sutures removed at 5-7 days
• Revision if required - 6 months
Complications
• Infection
• Dehiscence
• Vascular insufficiency due to
• Mechanical tension
• Kinking
• compression
• Hematoma/seroma
• Failure/necrosis
FLAP NECROSIS
The process is slow during which time the margin gets revascularised
from surrounding tissues, due to which the area of final necrosis
instead of being the entire distal flap , is an island in its centre.
• Length:Width
increased width of base
would increase surviving
length but feeding vessels
have same perfusion
pressure
• Perfusion pressure
PREVENTION OF FLAP NECROSIS
7. No compression at pedicle